Pre-licensing visit·July 28, 2021

Licensing Program Analysts (LPA's), Linda Almaraz and Nina Galarza conducted a visit to the above facility for a PRE-LICENSING evaluation. LPA's met with Licensee, Deborah Davis, Administrator Dan Davis, and CFO Chad Davis. LPA's did a walk through of the facility with the assistance of Administrator, Licensee and CFO. Structure: Facility is a (6) bedroom, (2) bathroom, single-story house. Room #2 is a staff room, for live in staff. The home has a living room, dining room, large kitchen, laundry area, office room and an extra living room for activities. There is a backyard with a covered patio area with furniture and shade. The residents bedrooms are spacious and will easily accommodate the resident's furnishings. The facility also has a garage that will not be accessible to residents. Signal system: All exits doors are equipped with a sensor type alarm systems which alerts staff. Bedrooms Residents: Bedrooms are approved for non-ambulatory residents. All rooms can have house bedridden residents. All bedrooms have the required bed(s), chair(s), night stand(s), and lamp(s). Each resident has a closet and plenty of drawers. Rooms also have a hand washing sink. Laundry Room: Laundry room has a washer and dryer. Laundry supply is secured and locked separately. Bathrooms: All bathrooms have a working toilet, wash basin, shower. There is two (2) bathrooms in the facility. (Continued on an LIC-809-C) Residents Records & Staff Files : Applicant will not be handling cash resources of residents, therefore no Surety Bond will be required. Records of staff and residents shall be stored in a locked cabinet. The facility will maintain all locked files in the office room. Reading Material, Games, Equipment & Materials: The facility has board games, crossword puzzles and other recreational materials for the resident's to use. Fire clearance: Fire Clearance was approved on 6/3/21. Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance was discussed. An exit interview was conducted and a copy of this report has been furnished to the Licensee Applicant. Accordingly, LPA will submit a copy of this Facility Evaluation Report to the Central Applications Unit (CAU) for review. If Licensee Applicant Representative has questions regarding the status of the application, they have been instructed to communicate with their CAU Analyst assigned to process their application. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blankets and bedspreads. Adequate supply of linen stored in the laundry room. Emergency Phone Numbers, Exit Plan & Menu: Facility’s telephone system is landline. Numbers posted & readily available for review. Fire Extinguishers are located in the kitchen, hallway and garage. Food Service: Dishes, cups and utensils are stored in the kitchen inspected and in good repair. Food supply adequate for seven (7) days of non-perishables. Dishwasher in kitchen properly installed and functioning. Smoke Detectors: Electrical & connected and appear to be operational. Licensee provided documentation from inspection conducted in 5/2021. Carbon monoxide detector are located in the hallway and near the kitchen are operational. Appliances: Stove burners, oven, microwave, washer, and dryer working. There is four (4) refrigerators in the home, a small one is located in the office room which will be utilized for refrigerated medication, one in the kitchen for food, an extra one in the garage and another small one in the living room. The facility is equipped with central air and heating and each residents bedrooms are comfortable in temperature. Water Temperature: Tested at 105.9*F in bathroom #1 and 114.0*F degrees in bathroom #2 . Medications, First-Aid Kit & Book: A first-aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, and current first-aid manual, which are stored in the office room, locked in the medication cabinets, available for staff use but inaccessible to residents. (Continued on LIC 809-C)